Wednesday, December 09, 2015

How history repeats itself when we plan for OT Anniversaries!

Near the beginning of this series on the history of the occupational therapy profession I documented how many of the details about George Barton and Consolation House were beginning to fade.  A concerted effort near the 50th anniversary of the profession helped to preserve some memory and connection to Consolation House, but planning for this event was very complicated.

I was excited today to hear that there was some beginning plans to commemorate the occupational therapy Centennial by having some ceremony or re-dedication plaque in Clifton Springs.  This is all in the beginning stages of planning, but it reminded me about the initial plans to celebrate the 50th anniversary in Clifton Springs.  I thought I would share some of the source documentation that went into that planning.

During the planning stages for the 50 year celebration the Consolation House was privately owned by Mr. William Wright.  Here is a letter that was written to Mr. Wright from AOTA President Florence Cromwell outlining some of the details associated with the plans for the 50th Anniversary Celebration.  You will have to click on the letters and documents to see them in full size and resolution.:

 


Here is a picture of the proposal for the 50th Anniversary plaque that was placed on the Consolation House property:



There is an interesting backstory about the marker.  In correspondence there was debate about where to place the marker.  The original plan was to place the marker between the sidewalk and the street.  Mayor Copeland obtained approval from the Clifton Springs Board of Trustees and he felt there were advantages to having it in a more 'public' space. Here is a letter from Mayor Copeland indicating that the Village approved a public space but that it seems there was a change to place the marker on Consolation House itself:



AOTA President Florence Cromwell replied, indicating that it was Mr Wright's (the property owner) preference that the plaque be placed directly on the house:



Communicating by postal mail between California and New York in a constricted time frame made coordination of plans for this event a little difficult!

These are all small but still interesting details of how the planning progressed to celebrate the 50th anniversary of the OT profession.  The reason why I found this particularly interesting is because of a casual comment made to me by someone who informed me of plans to possibly organize a Centennial ceremony or re-dedication plaque in Clifton Springs.  The plans are complex and involve local folk in Clifton Springs, the New York State Occupational Therapy Association, and the American Occupational Therapy Association. 

The comment was, "Getting everyone talking to each other seems to be the biggest challenge."

Apparently, the challenges of coordination and communication may be no different than they were 50 years ago!  I am sure that just like then this will also eventually come together into a very nice plan - but it is amazing  how history repeats and repeats itself!

Tuesday, November 24, 2015

Analysis of the AOTA claim of a gender-based wage gap in occupational therapy


The American Occupational Therapy Association recently publicized a claim that although 90.9% of respondents in their workforce survey were women that male practitioners make 14.7% more than women, despite setting, years of education, or position.

 They added the following editorial comments: "Want to earn what you deserve and be more confident? You don’t have to join the boys’ club or be aggressive."

This is an interesting claim so I decided to research these statements and see if they could be validated.  Data on wage disparity was not previously collectible in OT because of low numbers of men responding to workforce or wage surveys.  There was a parallel problem in the nursing profession.  However, in a recent large scale study in the nursing profession (also dominated by women wage earners) male nurses made $5,100 more on average per year than female colleagues in similar positions (Muench, Sindelar, Busch, and Buerhaus, 2015).  However, the study reports that about half of that difference was accounted for by employment patterns and other measured characteristics like leaving the profession to raise children.  That leaves a small difference yet unexplained.  An economist for the American Nursing Association also reports that there is some volatility in the statistics based on the low numbers of men in the surveys. 

Peter McMenamin, a health economist and a spokesman for the ANA states “The folks who did the study are well qualified and they have lots of data,” he said. “But my main hesitance in terms of statistics is they have fewer men.” Only 7 to 10 percent of nurses are male, he acknowledged. But with a smaller sample, he said, “the reliability of the answers is less robust.” 

In sum, it seems fair and reasonable to state that some wage gap may exist but that small numbers of survey participants and the presence of unexplained confounding factors makes up for some of that difference.  It also seems fair and reasonable that there are likely to be similarities between female dominated health care professions, such as between nursing and occupational therapy.  Therefore, it seems in-bounds to look at data from other similar professions.

There is no real argument that there has been a historic gender-based wage gap but as gender roles have changed and evolved over the last several generations that wage gap has diminished.  Goldin (2014) provides an exhaustive review of the evolution of what she terms "gender convergence."  In simple terms, changes in gender roles and education and societal views have helped to drive wages closer and closer to equality.  The wage gap shrinks based on "explained" reasons related to role behavior but there is still a "residual" gap that requires analysis.  She explains that some people would attribute that residual gap to blatant gender discrimination or even due to women's alleged inability to bargain.  These attributions are in line with the AOTA statements.  These attributions are also not fact-centric.

 Through detailed mathematical and statistical analysis, Goldin identifies that the residual gap exists "because hours of work in many occupations are worth more when given at particular moments and when the hours are more continuous.  That is, many occupations earnings have a nonlinear relationship with respect to hours.  A flexible schedule often comes at a high price, particularly in the corporate, financial, and legal worlds."  Again, in simple terms, workers who require and/or take advantage of workplace flexibility do so at the peril of their own salaries.  It is a mathematically proven reality.

Therefore, evidence for the gap is not directly gender-related.  However, it is true that gender roles remain persistently traditional despite move towards convergence.  Everyone can apply their own anecdotes to this: my observations are that despite theoretical advancements in 'equality' it is still more likely for women to advantage workplace flexibility in order to meet other occupational demands.  If there are non-OTs reading this, I use the term 'occupational' in its broadest possible sense.

There is a difference between gender-based inequality and role-based inequality. It is unfortunate that people will conflate these concepts in order to suit a narrative. 

Goldin's research is corroborated by a U.S. Department of Labor study (2009) that reports that the gap can be brought down from 23% to between 4.8% and 7.1% once all of the "explained" reasons are controlled (human capital development, work experience, industry factors, and career interruptions).

What remains is the summary fact that economic analysis accounts for large amounts of any reported "gender-related" wage gaps.  The residual differential is unquestionably related to ways in which women tend to interact with their work environments, and whether or not that is reported as "gender discrimination" tends to vary with the political motivations of whoever is presenting the facts.  Again, there is a difference between gender inequality and role inequality.  You don't have choice over your biologic gender.  You have a lot of choice about the way you engage your roles.

Obviously there are some pockets of blatantly gender-discriminatory behavior in isolated workplace practices.  I don't feel the need to cite evidence to support that belief because after 35 years of employment I feel confident in the knowledge that discrimination can exist.  The question then is whether or not there is a culture of discrimination against women in the occupational therapy profession.

Perhaps the best way to test for this is to search for evidence related to the American Occupational Therapy Association's claims.  They reported that in order to get the salary you 'deserve' that "You don’t have to join the boys’ club or be aggressive."

After an exhaustive review I was unable to find any evidence that there is any kind of "boy's club" in the occupational therapy profession that is acting to suppress wages of women occupational therapists.  However, I did find documented evidence of what Peters (2011) described as an "old girl's club" and an "old girls' network" that used strategies like networking and mentoring to achieve their goals.  Peters explains that "In this connected system, community insiders watched over each other’s tutees who had ‘‘the right’’ occupational therapy pedigree."

Interestingly, the woman-dominated occupational therapy profession had an internal culture of 'taking care of each other' often to the detriment of anyone who was an 'outsider' to that network.  Peters describes several examples of gender, racial, and other forms of outsider bias that was perpetrated by the 'old girls network.' 

That is rather ironic.

In a more positive sense, Peters states that the network also openly identified the problems associated with conflicting home life vs. work life tensions.  Peters cites Jantzen (1972a, 1972b, Mathewson, 1975) that 34% of occupational therapists stopped working after ten years to raise families.  She explains that "One drawback to this pattern is that work discontinuation led women to be in a poor competitive position with men... typically, women continued to work around family needs first, placing them in a weaker economic position than working men... women experienced stress when balancing roles including wife, mother, homemaker, and worker with limited time..."  She also quotes Robert Bing

The real problem in the 50s was the fact that a typical OT practiced an average of 3 to 4 years, then disappeared, usually into marriage.  The schools could not turn out enough additional people to cover this loss.

It seems reasonable to believe that this pattern of concern persists into the present day.  These issues of discontinuous labor participation are faced by many women who choose to have children and who choose to take 'breaks' from their paid employment.

Peters' history goes on in rather extensive detail in describing and quoting a history of the occupational therapy profession that overtly promoted feminism and that overtly discriminated against men, rejected symbols of male dominance, and fought against any residual influence of a male-dominated medical system.  Her examples are not restricted to single anecdotes; she describes a culture that was pervasive and that was extraordinarily slow to change.  Peters concludes that

 Occupational therapy as a female dominated profession did not collapse or subsume to more dominant professions like physical medicine... rather than deferring, these women embraced gender inequities using their female networking strategies to overcome challenges... rather than becoming male-like or medicine-like, this female dominated profession strategically glorified its feminization as it became scientific, thus providing a unique template to gender specific professions.

There is no evidence of some 'old boy's club' that current therapists must avoid in order to 'get the wages that they deserve.'  That modern day OTs are subject to some specious narrative of victimization by social forces is not only historically incorrect but also in direct opposition to the economic analysis of respected scholars who have correctly described the nature of 'residual' wage gaps.  The actual historic evidence supports Goldin's research that describes the way women engage a career trajectory in context of a desire to also balance other life demands.  This is nothing new; female occupational therapists have been experiencing and documenting these challenges for many years.  These challenges are largely based on personal choices and not on gender-based discrimination.

The correct message for the predominantly female field of OT is to understand that they are not subject to a 'boy's club' mentality that is 'aggressive' and that suppresses the wages that they 'deserve.'  They also don't need to 'negotiate' better because that is not the problem.  These are all false narratives.

In the past occupational therapists have advantaged the reality of their own 'old girls' network' in order to support each other and to push forward.  I expect that there are residual forces within the profession that reflect that culture.  That old culture was never low on facts and high on finger pointing or excuse-making. 

I can't imagine that 'old girls' network' tossing down a blame card of discrimination and imagining a phantom network of gender-biased men who are protecting the club and holding down women's wages.  The narrative put forward on AOTA's social media is not supported by evidence.  Specifically, that narrative is not consistent with economic facts as explained by Goldin and as historically recognized by occupational therapists themselves.  It is also just not consistent with the cultural reality of this female dominated profession and the documented way it has framed its own challenges.

So is there a gap?  Probably not much of one if you adequately controlled for all the factors.  It is clear that any gaps that do exist are related to individual and personal choices people make about labor participation.  Evidence shows that OTs have known this and have documented this for years - and it has always been described in terms of occupational choices, not gender discrimination.

If a member association wants to raise the issue of the problematic nature of measuring and understanding salaries that is fine and actually should be encouraged.  Framing it in exaggerated terms without including an honest analysis of current economics and historical precedents is probably not helpful.



References:

CONSAD Research Corporation (for USDOL) (2009).  An analysis of the reasons for the disparity in wages between men and women. Pittsburgh, PA: Author.  Downloaded from http://www.consad.com/content/reports/Gender%20Wage%20Gap%20Final%20Report.pdf

Goldin, C. (2014). A grand gender convergence: Its last chapter. American Economic Review, 104(4), 1091-1119.

 Muench, U., Sindelar, J., Busch, S.H., Buerhaus, P.I. (2015) Salary Differences Between Male and Female Registered Nurses in the United States. JAMA. 313(12), 1265-1267.   doi:10.1001/jama.2015.1487.

Peters, C.O. (2011) Powerful Occupational Therapists: A Community of Professionals, 1950–1980, Occupational Therapy in Mental Health, 27:3-4, 199-410, doi: 10.1080/0164212X.2011.597328

Tuesday, November 17, 2015

Sad days

"Today is my sad day," stated Lauren, in a matter of fact tone.

I work with many children who have superior language skills.  Often, those language skills outpace motor expression and emotional coping ability.  Sometimes doctors or psychologists call it a non-verbal learning problem or sometimes they will label it Asperger's Syndrome if the child has other behavioral quirks.  Either way, I am accustomed to hearing kids say things to me that would take the average listener off guard.

Lauren was a quick-witted and confident child with uneven red bangs from her own attempts at hair-styling.  Besides those bangs she had long tangled curls cascading down her back because she could not stand having her hair brushed.  Lauren had a habit of curling and twisting her hair in her hands, contributing to the tangles.  The mom intended to cut her hair to her shoulders but Lauren bargained herself a delay because she wanted long hair and also because she had the ability to perform verbal calisthenics and get things that she wanted.

I was seeing her because she had attention problems and some motor delays.  I know better than to respond too quickly, so I let her comment sink in a moment.  "What do you mean that 'Today is your sad day?" 

She reached into her backpack and pulled out a picture, directing it under my nose in a way that made me have to move my head back in order to focus.

"Today is the day that my dad died."

This was another one of those moments that you can never really be prepared for, because what do you say to a child that waves that information right under your nose?

It was an older picture with a deep fold down one side.  It was a picture of a baby, supported in her father’s arms, who seemed to be reflexively lifting her head to look at the other people surrounding her.  The baby had red hair; I imagine that it was probably as red as her father’s was when he was her age.  Now his hair was light brown.  As the baby looked at the strangers her dad teased the small curls in her hair with his fingers. 

"This is a picture of me and my Dad."  I knew that Lauren's dad died when she was a baby - her mom mentioned it to me during our first interview.  I started considering the pieces of the information that Lauren was giving me, and the implications of her statements started to fit together.

I stared at the picture and I thought how beautiful it was.  That dad loved his daughter.  Maybe his own parents held him the same way.  How else could he so effortlessly and perfectly hold his own daughter?  It was a perfect picture. 

"My mom told me that I used to be really fussy and all I had to do to calm down was let my dad hold me." 

I thought that was kind of funny, because little Lauren perceived her own intrinsic sense of control extending back to her infancy, as if she was letting her father hold her.  Her personality was so ingrained and she was only eight years old.  That made me smile.

"My mom told me that I would let my dad hold me on his chest and that would always make me close my eyes.  He would close his eyes, and I would close my eyes, and I would just listen to his heart beating and beating.  Sometimes I think I can still hear it, like when I am going to sleep and if I put my head on my pillow in a certain way.  Mom said that I am hearing my own heart, but I think I am hearing something else."

I stared at the picture that Lauren held in front of me as she talked and talked.  I imagined that it was his intention to remember this story himself twenty years after the picture was taken, and that she would not.  Instead she was developing a narrative of the event and she was doing the remembering. 

Death does that, I guess.  It takes the natural order of things and turns it all upside down.  Lauren now carried the memories that her father intended to have.

The story is now created and reinforced with the help of her mom.  It was originally supposed to be a love story that her dad had toward her.  What remains is a sense of love, but it is not the original love itself - because she only knows the story.  For Lauren that will have to be enough.

I thought about her uneven bangs, and her desire for long hair, and her ingrained habit of tangling it all together.  Then my perception shifted and I saw Lauren as a young woman, with long red hair that she would twirl wistfully with her own fingers.  I imagined her sitting and twirling her hair and dreaming about what it would be like to be loved.

She will understand that her father loved her, but she will know how that love was shown through a  shared and reconstructed story that will be as real as remembering the event herself.  Even on the sad days.

Friday, October 16, 2015

Thought exercise for occupational therapists


Thought exercise:
Take special note of the 'Service to society' section 
[my emphasis added].  Are we still providing this service? 
Or are we now chasing some other objectives that are out of 
sync with this original intent? 





REPRINTED FROM:
CAREERS FOR WOMEN 
EDITED BY CATHERINE FILENE 

THE OCCUPATIONAL THERAPIST 

MARJORIE B. GREENE 

Registrar, Boston School of Occupational Therapy 

Boston, 1920.
 
 
Description of occupation 

Occupational therapy is one of the new professions for 
young women. The necessity and importance of this work 
was firmly established in military hospitals during the late 
war and its future success is secure. The civilian hospitals 
are waiting for trained workers, and we believe that it is but 
a short time before every hospital and institution will employ 
at least one aide. 

The training is designed to develop not only artistic and 
mechanical skill and dexterity, but also ability to cooperate 
with every branch of the hospital service in order that there 
may result the highest standard of efficiency. This latter 
ability is quite as important as the former. 

Among the crafts used for their special therapeutic value 
are: Applied design, basketry, block printing, bookbinding, 
chair-seating, jewelry, leather work, modeling, rug-making, 
textiles, tin-can work, typewriting, weaving, wood-carving, 
woodwork and whittling. Also minor curative occupations; 
bead work, colonial mats, cord work, crocheting, knitting, 
netting. The work is carried on in hospital wards and shops 
and, when possible, with private cases. 

Preparation or training necessary 

General education, equivalent at least to high-school educa- 
tion. 

Previous training in any of the following subjects with satis- 
factory credentials will be credited the student upon entrance 
to the schools of Occupational Therapy: nursing, social 
service, physical education, mechanical drawing, psychology, 
arts and crafts. 
 
 
Training may be secured at the following schools: 

Boston School of Occupational Therapy, 7 Harcourt Street, 
Boston. 

Teachers College, Occupational Therapy Department, New 
York City. 

Flavell School, Chicago, Illinois. 

Philadelphia School of Occupational Therapy, Philadel- 
phia. 

Downing College, Milwaukee, Wisconsin. 

School of Occupational Therapy, St. Louis, Missouri. 
 
 
Qualifications necessary for success 

Strong physique, understanding of human nature, common 

sense, initiative and adaptability. 
 
 
Financial return 

Average, from $1200 to $1800 per year. 
 
 
Extent of occupation 

Occupational therapists are in demand in institutions such 
as State hospitals, private hospitals, Army and Navy hospi- 
tals, dispensaries. Government public health departments, 
work with private patients both in hospitals and at home. 
The demand for well-trained aides far exceeds the supply. 
 
 
Service to society 

To restore a patient's courage and his, or her, maximum men- 
tal, nervous, and physical ability is to add an asset to the 
community where there might have been a liability. To bring 
work out of idleness has economic value in time, morality, 
production, health, and happiness, and is elevating to the 
individual and to the entire world. 
 
 
Suggested reading 

"Ward Occupation in Hospitals," Bulletin No. 25. Issued by 
Federal Board of Vocational Training, Washington, D.C., 1918. 
"Handicrafts for the Handicapped" — Dr. Herbert J. Hall. 
"The Work of Our Hands" — Dr. Herbert J. Hall. 
"Teaching the Sick" — George Edward Barton. 
"Invalid Occupations" — Susan Tracy. 

Tuesday, October 06, 2015

A tale of two Mertons


In her famous Slagle lecture, Reilly describes the importance of criticism in professions in general and in occupational therapy in particular.  She stated that
"...a card-carrying critic must do more than merely engage in critical thinking. Judgments made by a critic must emerge from a discreet use of techniques which are difficult to master and dangerous to apply. Basically, the skill is dependent upon an ability to analyze, interpret and synthesize. A critic must have a sharply developed capacity to see deficiencies in data and fallacies in interpretation. The best stock in trade that any critic has is a discerning eye for trends and an ability to pattern and verbalize them. Whether a critic is worth listening to is usually decided by an ability to use language well, by a creativeness in synthesizing new relations and by courage to propose provocative hypotheses. Ultimately, however, a good critic rests his case upon how well he has been able to restructure the issue so that the necessary powers for its resolution can be freed."

Reilly understood that these were difficult standards because in her estimation criticism was not commonly employed or understood in professional affairs at the time she gave her lecture.

Unfortunately, not much has changed in this regard in 50 years.  The AOTA is proposing changes to the Bylaws that create an environment that will discourage member participation.  The current proposed revisions are posted online at http://www.aota.org/AboutAOTA/Get-Involved/BOD.aspx.

The new Bylaws create a process where any member can complain and call for the removal of another member based on the poorly defined concept of 'cause.'  Such complaints would be the type of complaints that would not rise to a full ethics violation.

There is an ugly history of people using association processes to air their personal disputes. Just ten years ago there were published allegations that the SEC (ethics commission) was becoming a place where "conflicts of interest or personality disputes [were] coming before the commission."  (Glomstad, 2005).  An AOTA member made a motion to eliminate the SEC because "The story behind the motion reveals that the SEC also has become an arena for airing personal conflicts among AOTA leaders and members." (Glomstad, 2005).

There was a lack of specificity in the new proposal.  After it was pointed out that there was no procedure for managing complaints, a document was created.  It does not appear that the brand new "Standard Operating Procedure for Investigation and Determination of Complaints to Terminate Membership" has even been reviewed by the BPPC or approved by the Board.  That leaves the impression that this is being made up on the fly.

After pointing out that there was no real definition of "cause" some clarification was given.  The FAQ was updated and now states that "This definition of “cause” is consistent with the longstanding description of “cause” used in AOTA policies for removing volunteer leaders from their positions."

It does not make sense to apply standards associated with volunteer leaders to members because the conditions do not apply to members.  The definition of 'cause' as stated in Policy 1.15 Removal and Appeal have no application to normal members.
That policy states:

1. All elected and appointed volunteer leaders may be removed for:
    a. Failure to accurately report or maintain qualifications for the office or position held, including maintaining the credentials and criteria for eligibility for the office, or
    b. Failure to perform official duties of the office or position held as defined in the governance documents, or
    c. Failure to declare a material conflict of interest in violation of the Association’s official policy or other action/omission of influence, or
    d. Misuse of proprietary or confidential information, or
    e. Violation of any fiduciary duty, or
    f. Proven unethical behavior in the conduct of the position held or proven conduct that reflects negatively on the reputation of the profession or Association.

None of this applies to regular members, except ethics concerns, which should be handled by the ethics commission.  Therefore, there is no compelling definition of 'cause' to apply to members and that reinforces the concern that this has the potential for serious misuse and abuse.

Additionally, the "Standard Operating Procedure for Petition to Challenge Association Action" places the Board in a position where it is essentially investigating itself and hearing appeals on its own actions.  That is not a functional process and any organization that hears appeals of its own decisions without some kind of external and independent arbitration is not offering any 'reasonable opportunity' for defense.

It is difficult to understand what the purpose of this new policy is.  It creates an environment where members can complain about each other and where there is  show trial conducted by a Board that has not really defined a due process procedure or opportunity for any reasonable defense.  The Board would be better off spending its time on governance.  Since there is already an Ethics Commission it is very difficult to know what kind of 'lesser' complaints and interpersonal grievances might be heard by this new process.

If this new policy goes into effect the AOTA will have a new mechanism for quelling member participation.  Who would want to speak out about anything or even participate in AOTA if that means that someone might complain about what you are saying and subject you to some whimsical Board process that can lead to membership revocation?

Considering this new proposed policy is what caused me to review Reilly's statements about criticism.  In her lecture she quoted Robert Merton who was a sociologist; he wrote about the role of professional associations and how they are supposed to foster exchange of ideas.  Merton (1960) wrote:
It is here that they can exchange ideas, experiences, and information that have not yet found there way to the printed page.  Some of this exchange is of the kind that seldom, if ever, gets into print.  That is why even the best of scientific journals is not a complete substitute for the give-and-take that, in the effective professional association, is provided by national meetings and all manner of other conferences.  That is why the professional society is the indispensable complement to schools and universities.  It provides for an interchange that would otherwise not take place.

Such profound words, and such a shame that interchange would be threatened by policies that allow members to complain about each other and attempt to have each other's membership revoked.  Criticism, debate, and information exchange is impossible in such a context.

In Reilly's Slagle lecture she invokes a very unusual term when talking about this topic.  She states that according to Merton (1960), "criticism stings a profession into a new and more demanding formulation of purpose and maintains a policy position of divine discontent with the state of affairs as they are."

"Divine discontent" is the unusual term that stands out, because it is an entirely DIFFERENT Merton that is commonly associated with that term.

Trappist monk and Catholic writer/social activist Thomas Merton (1948) was also a 'card carrying critic.'  He was chronically discontented with the way things were.  Although his path was tortured, his criticisms and questioning were always oriented toward growth.  His inherently critical nature did not make for an easy path because he constantly acted as a pebble in the shoe of nearly every authority figure that he met.  That led others to even take steps to silence him and to forbid him from writing or speaking on certain topics that would cause 'trouble' or 'embarrassment' for his superiors.

That reminds me a lot of this new proposal from AOTA.  It is a policy that threatens people who want to be card carrying critics and it is an oppressive action that will limit exchange of ideas.  Such policies have no legitimate place in a professional association that I want to participate in, so I ended my own membership.

I will just borrow a line from that other Merton (1948) that Reilly oddly and accidentally brings to mind:

Sit finis libri, non finis quaerendi.



Reference:

Direct links, and...

Glomstad, J. (2005, April 4). A stormy transition.  Advance for occupational therapy practitioners, available at occupational-therapy.advanceweb.com/.../A-Stormy-Transition.aspx

Merton, T. (1948) The Seven Storey Mountain.  New York: Harcourt Brace.

Merton, R.K. (1960). The search for professional status.  American Journal of Nursing, 60, 662-664.

Reilly, M. (1985). The 1961 Eleanor Clarke Slagle Lecture: Occupational therapy can be one of the great ideas of 20th century medicine in AOTA (Ed.), A Professional Legacy: The Eleanor Clarke Slagle Lectures in Occupational Therapy, 1955-1984, (pp. 87-105). Rockville: AOTA.



Tuesday, September 22, 2015

Editing the American influence out of the history of occupational therapy

During the very long social justice debate that preceded the revised AOTA Code of Ethics there were repeated claims that social justice represented a Core Value of the occupational therapy profession.  Those claims have been thoroughly addressed here and here.  In these entries and several other previous entries information was presented to support the claim that American influences are germane to understanding the driving forces behind the formation of the profession.

In my ongoing readings related to this topic I was comparing textbooks and am developing some new questions.  I am very curious about information that was recently edited out of the new edition of the Occupational Perspective of Health, 3rd ed (Wilcock and Hocking, 2015).

In An Occupational Perspective of Health, 2nd ed., Wilcock (2006) discusses the driving forces leading up to the formation of the occupational therapy profession.  She explains that changes occurred as Ruskin and Morris' ideas (via the Arts and Crafts movement) were brought to the United States.  She writes

However, because the Puritan work ethic was so central to American culture, Ruskin's and Morris' conception of a preindustrial, creatively absorbed craftperson became reinterpreted so that eventually no distinction was made between modern and pre-industrial work habits.  American Arts and Crafts leaders, along with their progressive contemporaries, drew back from fundamental social change for social justice, favoring instead "a new kind of reform" aimed at "manipulating psychic well being" and fitting individuals into emerging hierarchies.  This notion of "mental and moral growth" was compatible with 19th century American ideas about individualism, which was central to capitalism, its liberal democracy ideology, and values focusing on human rights... Similarly at Hull House, where Ruskin's and Morris' photographs had pride of place, the Arts and Crafts ideology was reinterpreted from a socialist to an individualistic focus.

This analysis is in line with my previous essays on this topic and in my estimation this is an accurate representation that dismisses the fallacious 'Social Justice as Core Value' argument.  Unfortunately, this entire section has been edited out of the 3rd edition of the same text.  Instead, Wilcock and Hocking (2015) offers this:

Neither the antimodern socialist revolution focus, nor the capitalist, individualist growth focus, nor the establishment of occupational therapy was successful in creating global awareness of the need to consider people's inner being and occupational nature in future social or health planning, although all went some way in that direction.  Later, the dominance of reductionistic medicine led to public health practitioners being tied to a practice geared to civic sanitary conditions and control of epidemics of infectious diseases, and the diminution of broadly based, population-focused occupational approaches to health, delaying a collective consciousness of their importance.

So an accurate analysis of the American forces that shaped the unique focus of the profession is now removed and we are left with an accusation that those influences were detrimental to what I will label as Wilcock's and Hocking's Occupational Therapy New World Order, which is all based on a new justice paradigm.  This is consistent with other academic efforts to bend history in order to fit a social justice narrative.

I am wondering if Wilcock's original analysis is edited out of the 3rd edition discussion because its presence undercuts the arguments of social and occupational justice proponents. It is unfortunate that she did not EXPAND on this line of analysis and include information on the influence of the Transcendentalists, the Boston Society of Arts and Crafts, the Emmanuel Movement, and George Barton. This all becomes immensely important as it relates to our theory development because it helps us to answer questions about whether or not that American influence is important.  I argue that it is, and that is why I spend so much of my research time attempting to reconstruct the neglected Barton thread of the occupational therapy story.

These topics are important for uncovering the full truth about our historical roots and Core Values.  When we omit important historical facts and analysis we have incomplete information to form proper opinions.  This kind of cherry picking has led some scholars to misinterpret history and to oddly focus only on justice models or feminist interpretations of Hull House influences.  A proper historical analysis will balance all of these factors together and will not selectively edit anything out.

History should be history.  It should not be selectively edited and it should not be revised to suit current political and justice agendas.

References:

Wilcock, A.A. (2006). An Occupational Perspective of Health, 2nd ed. Thorofare, NJ: Slack, Inc.

Wilcock, A.A. and Hocking, C.H. (2015). An Occupational Perspective of Health, 3rd ed.  Thorofare, NJ: Slack, Inc.


Monday, September 21, 2015

I vaant to TELL you zomething!

I want to share a message about authenticity in therapeutic relationships.

Jim was a 40 year old man who participated in  a day treatment program in a rural community.  The program itself was conceived and nurtured by Jim's parents along with other parents who were desperately trying to find non-institutional program options for their children.  Jim had cerebral palsy and an intellectual disability.  He attended that community program as a school child and eventually 'graduated' into the adult day treatment program.  The program grew from providing services to just a few children to several hundred people with developmental disabilities of all ages.  The program was an act of love, gifted by parents to their children.  That is the best way I can think to describe programs that developed this way.

I am not sure how aware Jim was of all that.  He was mostly focused on relationships with people and he had no disability in that social arena.

I had no special relationship with Jim, except that he treated all of the people that he interacted with in a special way.  Because of that I loved spending time with him.  Who doesn't love spending time with someone who treats them like they are special?

You could always hear Jim before you could see him; he had an uncanny ability to know where you were before he could see you.  Perhaps because his vision was poor and his motor abilities were limited he compensated with hearing or something else.  He would slowly wheel himself from around a corner, propelling his wheelchair mostly with small wrist movements, and you would hear a characteristic voice with his 'fake' accent that sounded like something out of a Dracula movie: "Chreeeeeestopherrrr.... I vaant to TELL you zomething!"

I have no idea where he got that 'voice' from.  Just remembering his voice cracks me up as I think about it.

Five years after I left that facility I was working in a children's hospital in a nearby city.  I was working in the orthopedic clinic and I heard that voice from behind one of the closed curtains in an evaluation room, just as if those five years had not even passed.  The voice said clearly, "Chreeeeeestopherrrr.... Eeez Zat YOU????  I vaant to TELL you zomething!"  Of course it was Jim - who despite his age was still being followed in the developmental disabilities clinics of that pediatric hospital.  I couldn't believe that he knew I was there even though he couldn't see me from the other side of that curtain!  It was a wonderful reunion, like seeing an old friend again.

There is a special authenticity about those kinds of interactions that is very difficult to explain in words in some blog post.

I got to thinking about this because I was recently reminded about this kind of authenticity in my work at the college.  The college has a transitional program for young adults who have developmental disabilities.  Those students attend educational classes, some of which are college courses.  They are not graded on their efforts but the idea is to promote inclusion and participation.  I was fortunate enough to have some of those students in a Freshman level 'Intro to OT' course, and even though I think that the program needs more OTs working in it in a general sense, the participation of those students in the class was positive in just about every way I might think to measure.

What struck me most though was that as the next semester began I would pass by some students from my Intro to OT course as I walked around campus.  The students were always polite and friendly, perhaps verbalizing a quick 'hi' or giving a quick head nod along with a fleeting moment of eye contact as they rushed around campus.

That is not how the 'Intro to OT' students from that transitional program acted though.  The first response that I got when I saw them was quite different.  They ran to greet me, excited to tell me about their summer experiences.  One asked for a hug.  And it wasn't just that first time, because now they stop by my office or stop me to talk when I am walking around the halls.  One of them still wanted to talk about the book I had them read last semester, Tuesdays with Morrie.  I think that even though the writing skills are imperfect, one of those students really understood the message in the book.  That student wrote:
Morrie said that “This  is  a  part  of  what  a  family  is  about,  not  just  love.  It’s  knowing  that  your family  will  be  there  watching  out  for  you.  Nothing  else  will  give  you  that.  Not  money.  Not  fame.  Not  work.”  So What  does  this  mean to me?  To  me,  it  means  that  yours  or  my family--mothers,  fathers,  brothers,  sisters,  aunts,  uncles,  cousins,  grandparents,  friends, teachers etc. will be  by  our  sides  no  matter  what.  It  doesn’t  mean  who’s  just  in  our  blood,  it  also  means who  our  friends  are  who  take  us  in  as  their  sister  or  brother.  You  could  be  famous  person  and  still  need  your  mom  or  dad  to  support  you.  You  could  have  a  job  that  has  a  bunch  of hours  and  pays  at  minimum  wage  while  still  being  happy  with  what  you  have. Families are  important  in  our  lives, no matter who we are calling family.  And we should probably dance with them if we love to dance.

So, I vaant to TELL zomething to OT students who I hope will also have the opportunity to work with people who have developmental disabilities during their careers.  It is pretty important that we learn to strip away and look beyond the labels that are placed on people.  Sometimes we find ourselves working within systems that apply those labels for what are supposed to be good reasons but sometimes they distract us from understanding that people of all abilities have some important observations to offer and some important contributions to make. 

I am not trolling for hugs next semester from my Freshmen students, but I think it is correct to observe that we have a lot to learn from each other, even when our abilities and skills are very different.  In particular, I think that we all have more to learn about how we are supposed to care about each other and how we can interact with each other in more authentic ways.

The whole idea of inclusion is that it opens us up to opportunities to interact.  It is never going to be enough to just interact though.  We have to open our hearts to each other and learn to listen closely to the messages that people have and that we can learn from.

Sometimes they come hidden in fake Transylvanian accents.  Sometimes it will come in an essay.  Sometimes it will come in the happiness that people experience when you stop long enough to treat them like they are important. 

You just never know, and that is why you always have to watch closely for those lessons when they come your way.


Tuesday, September 08, 2015

Narrative summary of the ACOTE Occupational Therapy Entry Level Survey

*This represents MY Summary and opinions on this report:

As part of the process of gathering data to inform decision making regarding the entry level degree required for occupational therapy practice, the Accreditation Council on Occupational Therapy Education conducted a survey.

In summarizing these statistics, categories of respondents were combined to simplify analysis.  Also, in summarizing agreement or disagreement, categories of 'strongly agree' and 'agree' were combined as were 'strongly disagree' and 'disagree.'

That survey was open between March 13, 2015 and closed May 15, 2015.  There were 2,829 respondents.  The generalized categories of respondents were OT practitioners (50%), OT students (19%), OT academicians (29%),and employers (3%).

The overwhelming majority of respondents (71%) agreed that the OT profession should embrace a single entry level.  This opinion was similar across all categories of respondents.

When asked if the body of OT evidence would benefit if the entry level degree moved to the doctorate, 61% of respondents disagreed.

When asked if if a doctoral entry level degree would allow for an increased impact on healthcare reform, 61% of respondents disagreed.  Practitioners in particular disagreed with this statement (70%).

When asked if moving to an entry level doctorate would positively impact practice on the respondent's particular region, 69% disagreed.  Practitioners in particular disagreed with this statement (78%).

When asked if such a change would positively impact students, 70% disagreed.

67% of respondents did not think that a doctoral entry level degree offered more opportunity for promotion.    Only 23% of practitioners thought it could offer such opportunity as opposed to 43% of educators who thought it could offer such opportunity.

 Securing fieldwork placements was a concern of the majority of respondents (66%).  Most respondents (57%) did not believe that academic institutions are positioned to meet the changing needs of OT programs.  70% of respondents believed that there was a lack of qualified faculty, 40% believed that there was a lack of State support, and 42% believed that there was a lack of institutional support.  72% believe that an entry level OTD will decrease the number of applicants to OT programs, and 64% believe that it will decrease the diversity of applicants.  Only 12% of respondents believed that no challenges were anticipated.

Cost was a significant concern; 74% of respondents believed that the cost of a higher entry level degree would not be worth any benefits that it might bring.

Employers responded in an overwhelming fashion (82%) that they are not more likely to hire OTs with a higher entry level degree.

Most respondents overwhelmingly felt that the current degree requirements were sufficient: 92% believed that basic tenets were sufficient,  90% believed that theoretical perspectives were sufficient, 87% believed education on evaluation was sufficient,  85% believed that education on intervention was sufficient, 89% felt that education on service delivery context was sufficient, and 94% believed that education on ethics and professional responsibilities was sufficient.   Beliefs on sufficiency of education on scholarship (79%) and management (82%) were lower, but still rather high.

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Editorial:

The ACOTE decision to support dual entry into the profession is in opposition to the AOTA Board of Director's opinion on the doctoral degree as a single point of entry.  The recommendation is certainly not based on survey results alone.  However, the largest concern for the OT community should be the overwhelming and consistent difference of opinion between this survey and the responses and recommendations of the AOTA Ad Hoc Committee on the Future of Occupational Therapy Education and the AOTA Board of Directors.

The future of this doctoral issue remains uncertain, but the OT community should study the results of this survey and attempt to understand why the OT leadership would come to a conclusion that is so apparently out of step with its membership and other stakeholders.

Based on previous analysis, there was a concerning lack of diversity on the Ad Hoc committee.  That committee was composed almost entirely of academics.  I reported on the concern 18 months ago when the recommendation for the OTD was made:

The AOTA Board informed their decision on two workgroups: one an Ad Hoc Board Committee on the Future of OT Education chaired by Dr. Thomas Fisher and the other an internal subcommittee of the Board itself that reviewed the Ad Hoc Committee's findings.

The Ad Hoc Committee was comprised of occupational therapists who also served as Deans, Provosts, or other high ranking University officials as well as the AOTA Director of Accreditation and Academic Affairs.  Task groups were developed to address specific questions.  Specifically, one task group called the "Maturing of the Profession" task group made the specific recommendation for mandatory doctoral level education.  This group consisted of a physical therapy educator/Dean and four occupational therapy academics who all held high ranking University positions.

It is not known who comprised the sub group of the AOTA Board of Directors that looked at the Ad Hoc groups findings.  However, the AOTA Board of Directors is known to be heavily weighted with those who work in academic settings.  Among those who are not currently in academia, most either hold dual academic appointments, have held academic appointments in the past,  or are in senior administrative positions in their work settings.

The fundamental problem with the composition of these committees and task groups is that they are making recommendations that stretch outside the confines of academia.  The recommendation for mandatory doctoral level training is not an academic recommendation.  It is a practice recommendation.

The ACOTE survey provides a rich data set that reflects the position of a more diverse group of stakeholders.  Perhaps even more importantly, the survey represents an opportunity for the AOTA Board of Directors to reflect on how they constitute Ad Hoc committees and how they might promote more diverse engagement from the entire occupational therapy community in the future.

Saturday, August 29, 2015

Investigating the status of "The Pledge and Creed for Occupational Therapists"

A little over a year ago I presented an argument that the Emmanuel Movement provided important core values for the occupational therapy profession.  This argument was constructed in context of a debate on whether or not Social Justice was a historical value of the profession.

I was curious as to why we neglected to include the Emmanuel Movement when we discussed our values and beliefs.  In the beginnings of the 20th century the Emmanuel Movement was based on the notion that a new method was required to address the social problems of disability and illness.  That new method was a philosophy regarding responsibility and self reliance - and surrounded by Christian values of charity.

Furthermore, that method was most certainly not based on a governmental model of redistribution or in a new age construct of oppression and liberation.  That fact is what made some of the recent social justice debates so curious.


Shannon (1977) warned that "a discipline that forgets its founders may be lost."



I have been studying these Values and Beliefs articles for a couple years and I recently noticed something that seemed to be missing.  In the initial article for the series covering the dates from 1904-1929 there is no mention of the  Occupational Therapy Pledge and Creed.  Certainly a Pledge and Creed would be an important document that would reflect both values and beliefs. 

The Occupational Therapy Pledge and Creed was submitted by the Boston School of Occupational Therapy and adopted by AOTA in 1926.  What is noteworthy is that the Pledge and Creed is mentioned in the book of one of the authors of the Values and Belief series (Reed and Sanderson, 1999, p. 408).  The Pledge and Creed states:


REVERENTLY AND EARNESTLY do I pledge my whole-hearted service in aiding those crippled in mind and body.

TO THIS END that my work for the sick may be successful, I will ever strive for greater knowledge, skill and understanding in the discharge of my duties in whatsoever position I may find myself.

I SOLEMNLY DECLARE that I will hold and keep inviolate whatever I may learn of the lives of the sick.

I ACKNOWLEDGE the dignity of the cure of disease and the safeguarding of health in which no act is menial or inglorious.

I WILL WALK in upright faithfulness and obedience to those under whose guidance I am to work, and I pray for patience, kindliness, and strength in the holy ministry to broken minds and bodies.


Most interestingly, Reed and Sanderson document that this Pledge and Creed "remains official today" when their book was published in 1999.  Since Reed wrote about the Pledge and Creed in 1999 certainly she was aware of it when she wrote the Values and Beliefs series.  I am not sure why it would not be mentioned in the series.

I have not been able to locate any documentation or announcement that this Pledge and Creed has ever been rescinded but this is an area that I am continuing to investigate.

Aside from the curious omission from the values and beliefs series it is important to note that such a Pledge and Creed incorporates a view of occupational therapy that is at severe odds with the changes that have been espoused by some therapists in the last twenty years.  Values of social justice, political redistribution of resources, client-based ethics, and redefinition of who we provide services to (whole communities, agencies, non-human entities, etc) are all severely out of step with the Pledge and Creed.  

The words 'pray' and 'holy ministry' are certainly interesting and I wonder if that is why the Pledge and Creed are not mentioned by those who espouse a secular interpretation of occupational therapy history.

I am not advocating the position that OT has to be explained in Christian terms but perhaps the inability to advance and explain the spiritual dimension of practice is why we have become so lost with our definitions. The existence of the Pledge and Creed presents itself as a philosophic conundrum for the profession.  

The Pledge and Creed is not on the AOTA website.  Has it been rescinded?

Does it 'remain official today?'

Is it the will of the association to rescind the document if it has not already been done?

If not expressed in specific terms of Christian ethics, how does the occupational therapy profession express its interest in spirituality?  We have lost our way on this topic. Howard and Howard (1997) asked "What does spirituality have to do with occupational therapy?"  They mentioned the early influence of the Immanuel (sic) movement, but it is clear that even in attempting to cover the topic that they apparently missed the mark.  Christiansen (1997) stated that "by failing to acknowledge a spiritual dimension, occupational therapy practitioners lose important opportunities for understanding the full potential of occupation to enhance the health and well-being of clients."

Egan and Swedersky (2003) state that "given the diverse definitions and the multiple meaning of spirituality in practice it is perhaps not surprising that studies of American, British, and Canadian occupational therapists are unsure of the role of spirituality in practice."

But even with these acknowledgements of spirituality in practice we have approached the subject as if we are doing so for the first time.  What an unusual position for a profession to be in when its very roots were based in a notion of mind-body-spirit healing!

References:

embedded links, and...


Christiansen, C. (1997).  Acknowledging a spiritual dimension in occupational therapy.  American Journal of Occupational Therapy, 51, 169-172.

Egan, M. and Swedersky, J. (2003). Spirituality as experienced by occupational therapists in practice.  American Journal of Occupational Therapy, 57, 525-533.
Howard, B.S. and Howard, J.R. (1997). Occupation as spiritual activity.  American Journal of Occupational Therapy, 51, 181-185.

Sanderson, S.N. and Reed, K.L. (1999).  Concepts of occupational therapy, 4th ed. Philadelphia: Lippincott, Williams, and Wilkins.

Shannon, P.D. (1977). The derailment of occupational therapy. The American Journal of Occupational Therapy, 31, 229-34.


Friday, August 28, 2015

Ethical occupational therapy practice in nursing home care

I teach ethical decision making to occupational therapy students.  One of the most common concerns that I hear from students each year is the pressure that they experience regarding productivity and 'meeting minutes requirements' in skilled nursing facilities.  Nursing homes receive higher rates of reimbursement based on intensity of rehab services that are provided, so there is an incentive for facilities to provide as much 'high intensity' therapy as possible.

Typically, the students express ethical distress because they often believe that the recipients of these services are receiving marginal or no benefit from their participation.

As a population, OT students feel disempowered about expressing concerns in this area during their fieldwork experiences because

a) they perceive that they are 'just students' and don't want to make waves
b) they feel confused because their clinical preceptors are all engaging in the behavior
c) they have competing pragmatic concerns, like graduating on time, having to find a new fieldwork, etc

Students report that many practitioners 'go along' with the push for more therapy because they become concerned with job security or that they simply accept these practices as 'being the way things are done.'

The Wall Street Journal wrote an excellent investigative article on this issue that I encourage others to read fully and carefully.  The article can be found here: http://www.wsj.com/articles/therapy-is-for-helping-patients-not-the-nursing-homes-1440539579

The article describes massive increases in therapy that advantage Medicare payment rules:

"The ultrahigh-therapy rise stretches from small operators to chains. Genesis HealthCare Corp., among the largest nursing-home providers, cited ultrahigh therapy in 58% of days for which it billed the system in 2013, a Journal analysis of Medicare data shows, up from 8.1% in 2002.

Kindred Healthcare Inc., which runs nursing homes and provides therapy at other facilities through its RehabCare unit, did so 58% of the time in 2013 at its own facilities versus 7.6% in 2002. Kindred and Genesis declined to comment.

HCR billed for ultrahigh services 68% of the time in 2013, versus 8.8% in 2002. In December, the Justice Department joined a whistleblower lawsuit alleging HCR pressured employees to provide unnecessary therapy and overbilled Medicare."

The leaders of the speech, physical, and occupational therapy member associations responded to the article with this letter that can be found here: http://www.wsj.com/articles/therapy-is-for-helping-patients-not-the-nursing-homes-1440539579

The response pays appropriate concern to the problem, but I believe that the member associations need to do more than simply "dialogue with industry to address the issue of volume-based versus value-based care and to improve compliance" and "help clinicians navigate complex regulation and payment systems, emphasize their responsibility to report unethical care provision and promote value-based patient care."

Some therapy groups named in the Wall Street Journal Article declined to comment but they also have direct relationships with the member associations, including sponsorships, clinical affiliation agreements, and other opportunities where they 'partner' with the member associations.

I believe it is reasonable to suspend these kinds of partnership arrangements until there can be a more thorough investigation about the practices of these companies.  Membership associations can't claim to be concerned about possibly unethical or even possibly illegal practices that are discussed in the Wall Street Journal article while they are forming partnerships with these agencies at the same time.

Writing a letter in response to the article only pays lip service concern, particularly when partnership agreements with these agencies remain in force.  Temporarily suspending partnerships pending investigations is prudent and sends a much stronger message about the actual concerns of member associations.  Partnerships can be renewed if there is no wrongdoing.  If there is wrongdoing, the member associations should not be partnering with these groups.

Monday, August 17, 2015

The occupational therapy profession's indecisive step toward its Centennial Anniversary

The Accreditation Council for Occupational Therapy Education released an unexpected set of decisions last week.

In sum, the two decisions promote the concept of dual entry levels for OTA education and dual entry levels for OT education.  The OTA dual entry (associates and baccalaureate) is an entirely new concept while the OT dual entry (masters and doctoral) follows a year-long debate on whether or not the profession should adopt the doctoral level as a single point of entry.

The reason why each of these decisions was surprising is because they contradicted the publicized opinions of the American Occupational Therapy Association, the member group for the profession.

As such the 'problem' with the decisions doesn't rest with ACOTE alone, but rather represents a community of professionals that are at odds with themselves and unsure of how to move toward the future.

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Regarding OTA education, an Ad Hoc Committee of AOTA looked at the complex issues surrounding OTA education and came up with three recommendations.  Those recommendations were:

1. Keep OTA education at the associate level
2. Have only one level of degree entry for OTAs
3. Articulate strategies to succeed if the association ever decides to transition to a higher degree level for OTAs.

The reports states that "While there may be some benefits to the two entry-level-degree model, they do not  outweigh the inconsistencies created when  there are  two different degree levels qualifying  graduates for a single set of entry-level competencies."

The full report is available at www.aota.org/.../OT-Entry-Level-Degree-ADHoc-Final.pdf

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Regarding OT education, an Ad Hoc Committee of AOTA looked at the complex issues surrounding OT education and came up with nineteen recommendations.  The most relevant regarding entry level was:

"AOTA adopt a mandate that entry-level-degree for practice as an  occupational therapist be a  doctorate by 2017 with a requirement for all academic programs  transition to the doctorate by 2020."

The full reports is available at http://www.aota.org/-/media/Corporate/Files/EducationCareers/Educators/Future-of-Education-Final-Report-2014.pdf

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The ACOTE decisions now recommend dual entry for both levels and apparently disregard concerns stated in the above reports in promoting what they are calling 'flexibility.'  ACOTE recognizes inherent difficulties with lack of differences in program outcomes between different levels, difficulties with infrastructure needed to support doctoral programs, and the paucity of fieldwork sites.  These are significant barriers that have been correctly identified.  The full statement is available at http://www.aota.org/Education-Careers/Accreditation/Announcements.aspx

Flexibility is certainly achieved by having dual entry points but also shows a profession that lacks leadership, direction, and ability to make definitive decisions and move toward a consensus.  In the parallel example of multiple entry points for the nursing profession, Smith (2009) states, "The requirements for entry into and completion of these programs vary by state and are controlled by forces within each state’s higher education system and healthcare-related interest groups, and the nursing profession itself."  This is what will also occur within the occupational therapy profession and is already on display in New York State.  A group of academicians, supported explicitly by the State OT board and tacitly by the State member association, is laying the groundwork for an eventual doctoral level entry point.  See here for details.

Not every state has interest groups that will powerfully drive the issue toward a conclusion.  There is a severe maldistribution of occupational therapy educational programs in the United States.  States with few or no programs and weaker State Associations might be among the last to promote a voluntary doctoral level entry point.  This will cause compounding problems with lack of consistency.

Smith (2009) lists several factors that likely contributed to the nursing profession's inability to agree on escalating degree requirements.  Use of a 'top down' decision making strategy was a major impediment that turned many nurses off of the idea of escalating entry level.  Also, the use of 'policy entrepreneurs' who were knowledgeable and well connected backfired on nurses because those people were not viewed as 'one of us' by the average nurse who would be impacted by the decision.  These same factors came into play for occupational therapy.

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Several actions are recommended in order to move the occupational therapy community to a consensus decision point.

1. Recognize that "flexibility" is a euphemism for indecision and confusion.  Study the nursing profession example to understand what "flexibility" has accomplished and not accomplished.

2. Place an accreditation moratorium on development of ALL entry level doctoral OT programs and baccalaureate level OTA programs.

3. Outline a process that will encourage a critical analysis of accreditation standards and align their minimal purpose with meeting evidence-based entry level occupational therapy practice competencies.

4. Develop profession-wide consensus on essential educational components based on practice analysis of entry level and advanced level skill sets through research.

5. Listen to and address the relevant concerns of the entire constituency that is impacted by such a decision: academia, clinicians, employers, the public, and other stakeholders.  Most importantly, don't drive this from a top-down perspective.

6. Develop final consensus based on a comprehensive consideration of ALL THE ABOVE.

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The current recommendation to promote dual entry levels will allow a condition of indecision to persist.  From a vacuum of indecision we can expect more special interest meddling from within different States.  We can expect a lack of uniformity that can complicate if not jeopardize third party reimbursements.  We can expect continued maldistribution of personnel.  We can expect uneven practice competency.

The occupational therapy profession is about to celebrate its Centennial Anniversary.  Confused and indecisive entry level education standards are not the way to put a best foot forward into a new century.
 

Reference:

Smith, T., (October 5, 2009) "A Policy Perspective on the Entry into Practice Issue" OJIN: The Online Journal of Issues in Nursing Vol. 15 No. 1.